I have a piece up at National Review in which I reflect upon Don Berwick’s controversial tenure as Administrator of the Centers for Medicare and Medicaid Services, the 800-billion-dollar federal agency that dominates the American health-care landscape. Despite White House rhetoric to the contrary, I write, Berwick “wasn’t done in by Republican intransigence. He was done in by presidential cowardice. And therein lies a microcosm of everything that’s been wrong with Obamacare.”

The thing to understand about Don Berwick is that there are really two Don Berwicks. There’s the Don Berwick who, through the Institute for Healthcare Improvement, has focused on apolitical aspects of health delivery reform. Here’s what I wrote about Berwick in April 2010:

First, the good. Berwick is a serious and credible health-care analyst. In his capacities both as a Harvard professor and as founder and CEO of a Cambridge-based think-tank called the Institute for Healthcare Improvement, he has written extensively about health-care policy in all of the leading scholarly journals. His focus, in most of these writings, is on the quality and efficiency of health care: things like avoiding medical errors and unnecessary spending. He was granted an honorary knighthood by Queen Elizabeth for his role in shaping Tony Blair’s (mostly futile) attempts to modernize Britain’s National Health Service.

While he was a big supporter of Obamacare, Sir Donald acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.

“But [those experts] would diverge on the most important questions of all,” I noted: “can and should, the state provide quality health care for all? Can enlightened, public-minded experts effectively manage one-sixth of the U.S. economy?” Here, it is not an exaggeration to say that Berwick’s views are difficult to distinguish from those of the central-planning advocates from old Cold War capitals. “You plan the supply; you aim a bit low,” Berwick once explained. “Historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them.”

But when Berwick was consulting for Britain’s National Health Service, he was unsurprisingly unsuccessful in centrally calibrating supply and demand. Technocratic health-care whack-a-mole has never worked, and it won’t work now. Most importantly, its main success is in denying British subjects the care they need and want.

There is probably no health-care system in the developed world today that would have delighted the old Soviets more than the British National Health Service. The state owns the insurance system; it owns the hospitals; it owns the clinics. People who try to seek health care outside the system are ruthlessly cut off. The “darkness of private enterprise,” as Berwick memorably described it, is hard to find in the NHS, which is why Berwick admires it so much.

It is, assuredly, comforting for Obamacare’s advocates to declare that Berwick was done in by partisan Republican squabbling. But the fact is that it was the White House that decided not to let Berwick go up to the Senate for a confirmation hearing, a hearing that Republicans were looking forward to. This was a blatant attempt by the President to avoid a proper, public debate between Berwick’s philosophy and that of his Senatorial critics. Perhaps Berwick would have won that debate in the eyes of the public. Thanks to the President, we’ll never know.

There is an important distinction here between the good and the bad of technocracy. Berwick’s career until roughly a decade ago was primarily focused on the need for better information about health and procedures—advancing information-sharing and creating more knowledge for doctors to utilize in pursuing the best outcomes. This is hardly a vile or morally problematic pursuit! Indeed, many on the right support gathering this information and sharing it with doctors with the speed of modern technology.

The problem comes when government steps in, and such information is used as a mandate sledgehammer to enforce central planning and rationing and against innovation and patient-directed care. The technocratic approach goes too far when it presumes that bureaucrats can process this data better than doctors, and that top-down management is the best (and indeed only) way to achieve the desired outcome. We see this fight regularly in the context of the Dartmouth Atlas. http://vlt.tc/sq The danger comes not from this more benign and even laudable pursuit of knowledge and measurement of success, but rather what comes when such immoral arithmetic becomes the top-down enforced mandates of unelected boards and faceless councils. The government overrules the doctor, and the patient is left with bad and worse choices—or a choice that comes too late to save their life. The much maligned Independent Payment Advisory Board by law cannot have a practicing physician serve on it—it is by definition rule by the faceless technocrats.

UPDATE 2: Tevi Troy, who served in the Bush Administration as HHS Deputy Secretary, has some insightful points on the Berwick bungle in response to an editorial from the New York Times. He notes, for example, that Obama could have nominated Berwick during the period in which he had 60 votes in the Senate, but chose not to:

The 18-month delay meant that the Obama administration missed the window in which they had a 60-vote Senate majority that could have confirmed him. Furthermore, the Senate had not even scheduled a hearing on Berwick before the Obama administration recess-appointed him, irking the Democratic chairman of the Finance Committee, Max Baucus. At that time, Berwick had not even completed all of the necessary paperwork for Senate confirmation, and a Senate source has informed me that he still has not completed all of his paperwork. Regardless, once the Obama administration recess-appointed Berwick without a hearing, Berwick’s chances of ever getting confirmed plummeted.